Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

Allowing the patient to ambulate independently

Administering a sedative to keep the patient calm

Placing the patient in restraints

Implementing a fall prevention protocol

Educating the patient on using the call light system

Answer and Explanation

Correct Answer : D,E

A. Allowing the patient to ambulate independently: This intervention is not appropriate for a patient who scores 30 points on the Morse Fall Scale, which indicates a high risk of falling. The patient should be monitored closely and assisted with ambulation to prevent falls.

B. Administering a sedative to keep the patient calm: While it may be important to keep the patient calm, using sedatives should be approached with caution, as they can increase the risk of falls and impair judgment and coordination. This intervention is not the most appropriate approach to fall prevention.

C. Placing the patient in restraints: Restraints should be used only as a last resort and only when necessary to prevent harm to the patient or others. Using restraints can lead to physical and psychological harm and should not be the primary intervention for fall prevention.

D. Implementing a fall prevention protocol: This is the most appropriate intervention for a patient with a high risk of falling. A fall prevention protocol may include measures such as ensuring a clear path, using assistive devices, and conducting regular assessments of the patient's mobility and safety.

E. Educating the patient on using the call light system: This intervention is important for ensuring the patient feels safe and can call for assistance when needed. Educating the patient on the call light system promotes communication and can help prevent falls by encouraging the patient to seek help when they need to move or ambulate.

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Correct Answer is C

Explanation

A. Bright red, bloody fluid: Bright red fluid indicates fresh blood, which is typically seen in the initial drainage from a surgical site or in cases of active bleeding. This type of drainage is not characteristic of serous fluid and may suggest a complication that requires further assessment.

B. Thick, green fluid: Thick, green fluid often indicates the presence of infection or pus, which would be classified as purulent drainage rather than serous. Serous drainage should not have a thick consistency or a green color, as this would suggest an inflammatory process or infection.

C. Clear, watery fluid with a pale yellow tint: This describes serous drainage, which is typically light in color and has a watery consistency. Serous fluid is a normal finding in the early stages of wound healing, as it contains plasma and does not indicate infection or excessive bleeding.

D. Milky, white fluid: Milky or cloudy fluid can indicate the presence of chyle (lymphatic fluid) or infection, which is not characteristic of serous drainage. Serous fluid should not appear milky, as this would suggest a different underlying issue that may need to be investigated further.

A. "I should get a longer cord for my telephone." B. "I should use chairs without armrests." C. "I should place a throw rug over electrical cords." D. "It is a good idea to use the handrails in the bathroom."

Correct Answer is D

Explanation

A. "I should get a longer cord for my telephone.": Longer cords can create tripping hazards, increasing the risk of falls. It is safer to use shorter cords or secure them properly to minimize risks. Keeping cords neatly organized and out of walkways is essential for maintaining a safe environment.

B. "I should use chairs without armrests.": Chairs with armrests can provide additional support for getting in and out of the chair, which can help prevent falls. Using chairs without armrests may make it more difficult to rise safely and could lead to losing balance during the process.

C. "I should place a throw rug over electrical cords.": Throw rugs can create tripping hazards. Placing rugs over electrical cords does not eliminate the risk and could further increase the likelihood of a fall. It's important to keep the area clear of both rugs and cords to promote safety and prevent accidents.

D. "It is a good idea to use the handrails in the bathroom.": Handrails provide stability and support when navigating potentially slippery areas, such as bathrooms, and can significantly reduce the risk of falls. Utilizing handrails allows individuals to maintain their balance and provides reassurance when moving in and out of the tub or shower.

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Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

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